Healthcare Provider Details

I. General information

NPI: 1104838036
Provider Name (Legal Business Name): ALBERT JAMES CREVELLO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 GREEN VALLEY RD STE E
FREEDOM CA
95019-3133
US

IV. Provider business mailing address

243 GREEN VALLEY RD STE E
FREEDOM CA
95019-3133
US

V. Phone/Fax

Practice location:
  • Phone: 831-722-8807
  • Fax: 831-722-8809
Mailing address:
  • Phone: 831-722-8807
  • Fax: 831-722-8809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA23870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: